1. Kidney Disease Workup – When to refer to Nephrologist
Family Practice Review
Feb 2013
4:30-5:30
Jeff Kaufhold MD, FACP
Master Physician, Ohio University Heritage School of Medicine
Nephrology Associates of Dayton

2. Renal Review
Now Kidney Disease- Work-up & When to Refer to a Nephrologist - What Drugs Not to Prescribe and What Drugs Work for Hypertension Mark D. Oxman, D.O.
5:30 p.m. - 6:30 p.m. Cloudy with Occasional Chance of Crystals: What You Can Learn from the Urine (Clinical Significance & Billing Codes and Reimbursment) Mark D. Oxman, D.O.

3. Pre Test
Which Treatment has the LEAST impact on progression of renal disease?
A. Use of ACE inhibitors
B. Referral to a nephrologist
C. Use of DHP calcium Channel Blocker
D. Control of Diabetes to A1c < 8.0
E. The nature of the underlying renal Disease

4. New Terminology ARF - RIFLE criteria
Risk low uop for 6 hours, creat up 1.5 to 2 times baseline
Injury creat up 2 to 3 times baseline, low uop for 12 hours
Failure Creat up > 3 times baseline or over 4, anuria
Loss of Function Dialysis requiring for > 4 weeks
ESRD Dialysis requiring for > 3 months

5. CKD prevalence in world Populations
Country Population CKD est.
China
India
Indonesia
Pakistan
Philipines
Vietnam
Assumes 2.72 % incidence

6. CKD Stages Stage 1. Normal function with known dz Stage 2. GFR 60-80
Stage 5. GFR less than 15.
Stage 6. ESRD on dialysis.

7. US Population with CKD
Coresh, Selvin, Stevens. Prevalence of CKD in the US. JAMA.2007;298(17)2038.

8. Approach as CKD progresses
GFR
----Stage Stage 4 Stage 5

9. Preparation of the Patient
Manage CRF
Stages 1, 2, 3.
Control BP
Preferentially with ACE
Control Diabetes with Target A1c < 8, based on the DCCT, ideally < 6.5
Careful with drug dosing
Prevent Hyper PTH
Vit D
Calcium acetate
Phosphate binder
Diet Education

10. Preparation of the Patient Stage 4 and 5
Manage Fluids
Dialysis education
Access Placement
Prevent anemia
Prevent Malnutrition
Start ACE?
metolazone
NKF program
AV fistula, PD cath
Epogen, Iron
This can get tricky
Stop ACE?

11. Medical treatment in CKD
Which drugs
To avoid,
and
Work for HTN

12. What Drugs to Avoid Drugs to avoid when GFR is less than 40:
NSAID’s
Bactrim
IV Contrast
Fleets Enemas
Metformin, Xarelto
For GFR less than 30, need to be careful with combinations of drugs like ACE and Spironolactone.

13. Which Drugs work for HTN?
Global treatment of HTN
Use of Common Medications in CKD
Steps to improve survival in CKD
Nephrologists approach to Hypertension Treatment.

14. Nat’l Health & Nutrition Exam Survey NHANES Control of Hypertension
JNC 7 Dec 2003

15. Medicare Part D & MarketScan CKD patients with at least one claim for an ACEI/ARB/renin inhibitor in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.14 (Volume 1)
Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

16. Medicare Part D & MarketScan CKD patients with at least one claim for a beta blocker in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.15 (Volume 1)
Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

17. Medicare Part D & MarketScan CKD patients with at least one claim for a DHP calcium channel blocker in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2009 Figure 2.16 (Volume 1)
Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

18. Prevalence of comorbidity in NHANES 2001–2008 participants, by risk factor, expanded eGFR categories, & method used to estimate GFR Figure 1.5 (Volume 1)
NHANES 2001–2008 participants age 20 & older.
Note how HTN is bigger problem as GFR falls

19. Medicare Part D & MarketScan CKD patients with at least one claim for a lipid lowering agent in the 12 months following the disease-defining entry period, by CKD diagnosis code, 2008 Figure 2.17 (Volume 1)
Point prevalent Medicare CKD patients age 65 & older & MarketScan CKD patients age 50–64.

20. Mortality rates in NHANES 1999-2004 participants, by eGFR: MDRD equation Figure 1.11 (Volume 1)
NHANES 1999–2004 participants age 20 & older.

21. Cumulative probability of a physician visit in the year following CKD diagnosis by physician specialty & dataset Figure 2.10 (Volume 1)
Only about 30 %
Patients alive and eligible all of 2008, CKD diagnosis represents date of first CKD claim during 2008, physician claims searched during 12months following that date.

22. How to improve CV Morbidity in CKD?
1. Early referral to Nephrology
2. Consider a patient with CKD 4 , 5, and ESRD
as having the same risk as a patient who
HAS ALREADY HAD THEIR FIRST HEART ATTACK.
Beta Blocker
Aspirin
Statin
restart ACE inhibitor or ARB
once pt on dialysis
To prevent a vessel wall thrombus

23. Hall Thrombus

24. Hypertension Case Presentation
56 y.o. A.A. male prior weight lifter presents for refractory HTN.
Normal labs and UA. Normal CXR and EKG.
Meds: Clonidine 0.2 BID
ACE inhibitor
Diltiazem 300 mg daily

25. Case Presentation
Physical Exam:
BP 170 / Pulse 85
Edema 2 +

26. Case Presentation Special populations help define your approach.
African Americans:
CHF
Diabetics:

27. Case Presentation Special populations help define your approach.
African Americans: Volume Mediated, Low renin low Aldo. May respond better to diuretics.
CHF: ACE, Diuretics, B-blocker, ASA
Diabetics: ACE or ARB.

28. Case Presentation 56 y.o. A.A. male with edema, HTN
Normal labs and UA. Normal CXR and EKG.
Meds: Clonidine 0.2 BID
ACE inhibitor
Diltiazem 300 mg daily
Whats Missing???

29. Case Presentation 56 y.o. A.A. male with refractory HTN.
Meds: Clonidine 0.2 BID
ACE inhibitor - Stopped
Diltiazem 300 mg daily
I added HCTZ 50 mg daily.

30. Case Presentation 56 y.o. A.A. male with refractory HTN.
Meds: Clonidine 0.2 BID
Diltiazem 300 mg daily
HCTZ 50 mg daily.
Still swelling, BP a little better / 100.

31. Case 56 y.o. AA male with refractory HTN.
I changed diuretics to Lasix and ultimately added Zaroxolyn.
I get a call 3 days later: Swellings gone, but I can’t get out of bed – too dizzy!
He had lost 15 lbs.

32. Case Presentation 56 y.o. A.A. male with refractory HTN.
Meds: Lasix 40 mg BID
Zaroxolyn 5 mg weekly
No swelling, BP 126 / 80.
Pt reports joint pain and swelling. What test do you order next?

33. Case Uric acid level is 12 Creatinine 1.4 K 3.8
Glucose 244 (nonfasting)

34. Case Started Allopurinol for gout.
Pt started exercising and watching diet.
Sugars normalized without treatment.

35. Joint National Commission
JNC founded on HDFP
JNC Intro of ACE, alpha B.
JNC Special situations
JNC Many agents 1st line
JNC Back to stepped care.
JNC ACE for Diabetics
JNC

36. HYPERTENSION JNC VII Outline
Epidemiology of HTN
Evaluation of HTN
NON Pharmacologic treatments: Wt loss, diet, exercise, alcohol
Drug treatment
Special Issues in HTN

37. HYPERTENSION JNC V
"Because diuretics and B-Blockers are the only classes of drugs that have been used in long-term controlled trials and shown to reduce morbidity and mortality, they are recommended as first- choice agents unless they are contraindicated or unacceptable, or unless there are special indications for other agents."

38. Stages of Hypertension
Normal
Prehypertension
Stage 1
Stage 2
< 120 / 80
/ 80-89
/ 90-99
> 160 / >100

39. Treatment of Hypertension
Stage 1 or Single agent – HCTZ for most pts B- Blocker for females/ high heart rate.
Stage 2 I start with DHP CCB (Nifedipine XL)
plus one or both of above.
Resistant HTN I look for CLASSES of agents

40. Classes of Antihypertensives
Diuretics
Rate control agents BBlocker, Verapamil, Diltiazem
ACE/ ARB’s
Vasodilators Dihydropyridines, Hydralazine, Alpha blockers, Minoxidil
Central agents: clonidine, aldomet.

41. Nephrology level htn
I tell the pt that we’ll need to control the main route plus the main detours causing the HTN.
Average of 3.1 medications to achieve control
Rate control (pulse < 78)
Diuretic
Vasodilator DHP CCB, Hydralazine, Cardura, Minoxidil.
ACE / ARB (accept 30% increase in creat if BP responds)

42. Refer to Nephrologist
If unable to control on 3 drug regimen which includes Rate control, diuretic.
If you are considering Minoxidil or renal angio.
If creatinine climbs more than 30 % or if creatinine is over 2.0.

43. Post Test
Which Treatment has the LEAST impact on progression of renal disease?
A. Use of ACE inhibitors
B. Referral to a nephrologist
C. Use of DHP calcium Channel Blocker
D. Control of Diabetes to A1c < 8.0
E. The nature of the underlying renal Disease